Chapter 32. Liver Transplantation

• End-stage liver disease in patients who meet the minimal criteria for placement on the liver transplantation list as defined by the American Association for the Study of Liver Diseases.
• Fulminant acute liver failure.
• Hepatocellular carcinoma fulfilling Milan criteria (tumor > 2 cm but < 5 cm or up to three tumors each < 3 cm).
• Some pediatric metabolic liver diseases as defined by the United Network for Organ Sharing (UNOS).

Absolute

• Recidivism to alcohol and drug abuse (6-month abstinence- free period essential).
• Significant portal venous thrombosis that precludes venous reconstruction.
• Extrahepatic malignancies.
• Systemic sepsis and certain untreated chronic infections (eg, tuberculosis, Mycobacterium avium-intracellulare).
• In the case of hepatocellular carcinoma:
  • Vascular or biliary tree invasion.
  • Tumors outside Milan criteria.

Relative

• Significant cardiopulmonary disease or other medical illnesses, with the exception of liver or biliary tree specific disease and renal disease.
• Certain chronic infections (eg, HIV infection).
• Profound physical deconditioning.
• Advanced age (older than 70 years).
• Poor psychosocial support (eg, homeless).
• Inability to obtain immunosuppressive medications.

• The patient should be supine.
• The left arm is extended and the axilla prepped in the sterile field (to provide access to the left axillary vein should venovenous bypass be required).
• The right arm can be tucked or extended.

• All patients are admitted to the ICU. The majority of patients remain intubated with the anticipation of extubation on postoperative day 1.
• Serial laboratory values are obtained (complete blood count, coagulation function, liver function tests).
• Immunosuppression.
• Oral medications (especially immunosuppression) are provided via nasogastric tube.
• Infections and other postoperative complications are treated in a similar manner to all other ill patients (ie, do not overtreat because the patient has undergone transplantation).
• Adequate nutritional support is of paramount importance in chronically malnourished patients with liver failure.
• Volume overload should be avoided.

• Potential complications are numerous.
  • Acute renal insufficiency is common.
  • Other specific complications include infections (bacterial, fungal, and viral), rejection, biliary complications, bleeding, primary nonfunction, hepatic artery thrombosis, and portal vein thrombosis.